[Injuries of the atlas]

J Stulík, M Krbec
Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca 2003, 70 (5): 274-8

PURPOSE OF THE STUDY: Injuries of atlas account for 1-2% of all injures of the spine and for 7% of the injuries of the cervical spine. Fractures of atlas occur either as isolated fractures or in combination with the injury of the axis or occipital condyles. The aim of the work is to evaluate a group of patients with the injury of the atlas treated both conservatively and surgically.

MATERIAL: Between January 1996 and October 2001 we treated at the Orthopaedic Department of 3rd Medical Faculty, Carles University in Prague 10 patients with the injury of atlas. Between November 2001 and December 2002 we treated at the Orthopaedic Department and Spondylosurgical Department of the Medical Faculty Motol another 5 patients with the injury of atlas. In 10 cases the fracture of atlas was isolated (anterior arch--once, 4 time Jefferson fracture, twice--fracture of massa lateralis), in 5 cases the fracture was associated with the injury of epistropheus (dens type II/posterior arch--twice, dens type II/Jefferson fracture--once, dens type II/massa lateralis--once, hangman fracture type II/posterior atlas arch--once). Teh group of patients included 9 men and 6 women of the average age of 46.6 years (range, 27-85 years). Eight patients were treated conservatively, 7 patients surgically. The most frequent cause of the injury was fall on the head or a severe downward violence in 7 cases, car accident in 4 cases, other causes vere identified in 4 cases. Neurological deficit upon admission was found out only in one patient (Frankel D).

METHODS: In isolated injuries of the anterior or posterior arch of atlas we always proceeded conservatively. The cervical spine was fixed for 12 weeks in the Philadelphia collar. One isolated fracture of massa lateralis was also treated conservatively for 12 weeks in the Philadelphia collar. Another case of the same type of fracture was treated surgically by C1-C2 by the Magerl technique supplemented on the intact side by the Gallie wire loop. Two stable Jefferson fractures were treated by the halo vest applied for 12 weeks. Two unstable fractures were handled surgically, once by C1-C2 by the Magerl technique and once by C0-C2 occipitocervical fixation. C1-C2 associated injuries were treated in four cases surgically, three times by a direct dens fixation and once by C1-C2 fixation after Magerl supplemented with the Gallie wire loop. A patient with the associated hangman fracture type II and fracture of the posterior atlas arch refused the surgery and therefore was treated by the halo fixation for 12 weeks. Philadelphia collar was applied to the patients operated on.

RESULTS: In the group of the conservatively treated, 3 patients complained of pain in the upper part of cervical spine and head requiring from time to time the administration of analgesics. All fractures healed within 12 weeks and the functional radiographs showed stable C0-C2 segments. As for complications, during the conservative treatment in one case a pyogenic secretion was recorded around the fixation elements of the halo apparatus requiring its removal after 8 weeks. The patient was further treated by a pelot fixation. In one case it was necessary to adjust twice the halo apparatus due to re-dislocation of the hangman fracture (associated hangman fracture of type II and posterior atlas arch). In spite of this the injury healed in C2-C3 subluxation, however, the fracture of atlas healed in a favourable anatomical position. In the group of the operated on, 2 patients complained of pain in the upper cervical spine requiring from time to time the administration of analgesics and one patient complained of a marked limitation of the range of motion by 50% (C0-C2 occipitocervical fixation). Also in this group stable C0-C2 segments were found out 12-14 weeks after the surgery.

DISCUSSION: In our group of 15 patients the fracture healed, i.e. stable C0-C1 and C1-C2 segments, in all patients treated both conservatively and surgically. In the group of conservatively treated patients there occurred in one case re-dislocation of the fracture. However, the patient refused the surgery repeatedly. Apart from these case we found in neither group any severe complication. The ratio of conservative and surgical treatment was 8:7.

CONCLUSION: Based on our own experience and the literary data we believe that suitable for the treatment of stable injuries of the atlas is conservative treatment, i.e. fixation in the Philadelphia collar for 12 weeks. In unstable injuries or intraarticular injures with dislocation we prefer surgical fixation of C1-C2 or C0-C2 in dependence on the type of injury. All associated injuries are indicated for surgical treatment.

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